Surrogacy Application

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By checking this box, you acknowledge the importance of honest and complete answers to the questions asked. We use the application to complete the screening process and find the best match options for you.*

Do you fully understand the commitment and responsibilities being a surrogate entails?*

No

Yes

Religious Affiliation

If you are a repeat surrogate, please list your surrogacy cycle details

How long have you been considering becoming a surrogate mother?

Please describe your reasons for wanting to become a surrogate mother?

Are you willing to be a surrogate mother for a single parent?*

No

Yes

Are you willing to be a surrogate mother for a gay couple?*

No

Yes

For additional compensation, would you be willing to be a surrogate mother for a HIV positive couple if the HIV was not passed down to you?*

No

Yes

Are you willing to carry twins?*

No

Yes

If you are willing to carry twins, please note twin pregnancies are considered higher risk pregnancies than carrying one baby. There are greater chances of bedrest and premature labor. Please acknowledge that you are willing to carry twins

I don't understand

I understand

If you prefer not to carry twins, there is less than a 5% change the single embryo could split naturally. If it did, would you be willing to carry both babies?

No

Yes

Are you willing to speak with the intended parent(s) by Skype or WeChat prior to matching?

Do you smoke cigarettes, use any nicotine products or use recreational drugs including marijuana?*

No

Yes

If yes, please provide details of any nicotine or recreational drug use.

Please acknowledge that at the time of medical screening and potentially throughout the process, you will be screened for nicotine and marijuana use. Please acknowledge you are ok with this and will pass these tests during your surrogacy journey*

I acknowledge

I decline

Do you have any current or past health concerns (describe)*

Do you have any history of high blood pressure?*

No

Yes

Have you ever been hospitalized other than giving birth? (describe)*

Have you ever been in therapy or counseling? (describe reason)*

When was your last pap smear?*

What were your pap smear results?*

Have you ever had an irregular pap smear?*

No

Yes

Do you have any allergies? (describe)*

Describe your diet*

Do you typically cook at home or eat out?*

Cook at home

Eat out

How often do you eat out?*

Do you currently exercise or work out? If Yes please describe your current exercise routine.*

Do you work out or exercise while pregnant? If so, what is your preferred form of prenatal exercise?*

Other

If bed rest is prescribed during pregnancy, will you require childcare assistance?*

No

Yes

Would you be willing to terminate pregnancy if medically advised?*

No

Yes

If the fetus is diagnosed with a fatal or debilitating disease, would you be willing to terminate the pregnancy if requested by the intended parents?*

No

Yes

If not immune to certain illnesses that could negatively impact the pregnancy for both you and baby, would you be willing to receive needed vaccines if required by the fertility doctor?*

No

Yes

If the fetus were diagnosed with Down syndrome (Trisomy 21), would you be willing to terminate the pregnancy if requested by the intended parents?*

No

Yes

If you were to become pregnant with more than triplets (3), would you be willing to reduce the number of embryos within the first trimester if requested by the Intended Parents?*

No

Yes

Please write at least a one paragraph biography about yourself and your family. The intend-ed parents will read this, they want to know a little about you and who you are. This is your chance to for the parents to know why they should choose you to be their surrogate mother.*

Please attached photos of yourself along with your family. (Please include family oriented photos. It’s ok to include selfies but please also include a photo or two that are not selfies)